In this Introduction, I situate the underlying project “Autonomy and Mental Disorder” with reference to current debates on autonomy in moral and political philosophy, and the philosophy of action. I then offer an overview of the individual contributions. More specifically, I begin by identifying three points of convergence in the debates at issue, stating that autonomy is: 1) a fundamentally liberal concept; 2) an agency concept and; 3) incompatible with (severe) mental disorder. Next, I explore, in the context (...) of decisional capacity assessments, the difficulties to reconcile 1) and 2) with 3) which they at the same time seem to imply. Having clarified the centrality of a cogent notion of mental disorder for addressing these difficulties, I comment on three promising lines of inquiry about the nature and scope of autonomy that emerge from the following chapters. (shrink)

This paper compares the free energy neuroscience now advocated by Karl Friston and his colleagues with that hypothesised by Freud, arguing that Freud's notions of conflict and trauma can be understood in terms of computational complexity. It relates Hobson and Friston's work on dreaming and the reduction of complexity to contemporary accounts of dreaming and the consolidation of memory, and advances the hypothesis that mental disorder can be understood in terms of computational complexity and the mechanisms, including synaptic pruning, (...) that have evolved to reduce it. (shrink)

In this paper, I present a challenge for Michael McKenna’s conversational theory of moral responsibility. On his view, to be a responsible agent is to be able to engage in a type of moral conversation. I argue that individuals with autism spectrum disorder present a considerable problem for the conversational theory because empirical evidence on the disorder seems to suggest that there are individuals in the world who meet all of the conditions for responsible agency that the theory (...) lays out but who are nevertheless not responsible agents. Attending to the moral psychology of such individuals will, I think, help shed light on an important gap in the conversational theory. (shrink)

This paper explores how the diagnosis of mental disorder may affect the diagnosed subject’s self-concept by supplying an account that emphasizes the influence of autobiographical and social narratives on self-understanding. It focuses primarily on the diagnoses made according to the criteria provided by the Diagnostic Statistical Manual of Mental Disorders (DSM), and suggests that the DSM diagnosis may function as a source of narrative that affects the subject’s self-concept. Engaging in this analysis by appealing to autobiographies and memoirs written (...) by people diagnosed with mental disorder, the paper concludes that a DSM diagnosis is a double-edged sword for self- concept. On the one hand, it sets the subject’s experience in an established classificatory system which can facilitate self-understanding by providing insight into subject’s condition and guiding her personal growth, as well as treatment and recovery. In this sense, the DSM diagnosis may have positive repercussions on self-development. On the other hand, however, given the DSM’s symptom-based approach and its adoption of the Biomedical Disease model, a diagnosis may force the subject to make sense of her condition divorced from other elements in her life that may be affecting her mental- health. It may lead her frame her experience only as an irreversible imbalance. This form of self-understanding may set limits on the subject’s hopes of recovery and may create impediments to her flourishing. (shrink)

People suffering from Obsessive-Compulsive Disorder (OCD) do things they do not want to do, and/or they think things they do not want to think. In about 10 percent of OCD patients, none of the available treatment options is effective. A small group of these patients is currently being treated with deep brain stimulation (DBS). Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes give a continuous electrical pulse to the brain area in which they are (...) implanted. It turns out that patients may experience profound changes as a result of DBS treatment. It is not just the symptoms that change; patients rather seem to experience a different way of being in the world. These global effects are insufficiently captured by traditional psychiatric scales, which mainly consist of behavioural measures of the severity of the symptoms. In this article we aim to capture the changes in the patients’ phenomenology and make sense of the broad range of changes they report. For that we introduce an enactive, affordance-based model that fleshes out the dynamic interactions between person and world in four aspects. The first aspect is the patients’ experience of the world. We propose to specify the patients’ world in terms of a field of affordances, with the three dimensions of broadness of scope (‘width’ of the field), temporal horizon (‘depth’), and relevance of the perceived affordances (‘height’). The second aspect is the person-side of the interaction, that is, the patients’ self-experience, notably their moods and feelings. Thirdly, we point to the different characteristics of the way in which patients relate to the world. And lastly, the existential stance refers to the stance that patients take towards the changes they experience: the second-order evaluative relation to their interactions and themselves. With our model we intend to specify the notion of being in the world in order to do justice to the phenomenological effects of DBS treatment. (shrink)

Psychopathy is often characterized in terms of what I call “the language of disorder.” I question whether such language is necessary for an accurate and precise characterization of psychopathy, and I consider the practical implications of how we characterize psychopathy—whether as a biological, or merely normative, disorder.

Dissociative Identity Disorder (DID) (formerly known as Multiple Personality Disorder) is a condition in which a person appears to possess more than one personality, and sometimes very many. Some recent criminal cases involving defendants with DID have resulted in "not guilty" verdicts, though the defense is not always successful in this regard. Walter Sinnott-Armstrong and Stephen Behnke have argued that we should excuse DID sufferers from responsibility, only if at the time of the act the person was insane (...) (typically delusional); otherwise the presumption should be that persons with DID are indeed responsible for their actions. We find their interpretation of DID and of the way in which the requirements for criminal insanity relate to this condition worrying and likely to result in injustice to DID sufferers. Our thesis is that persons with DID cannot be responsible for their actions if the usual features of the condition are present. A person with DID is a single person in the grip of a very serious mental disorder. By focusing on the features of DID which have, as we argue, the effect of deluding the patient, we try to show that such a person is unable to fulfill the ordinary conditions of responsible agency (namely, autonomy and self-control). (shrink)

Body integrity identity disorder (BIID), previously called apotemnophilia, is an extremely rare condition where sufferers desire the amputation of a healthy limb because of distress associated with its presence. This paper reviews the medical and philosophical literature on BIID. It proposes an evidenced based and ethically informed approach to its management. Amputation of a healthy limb is an ethically defensible treatment option in BIID and should be offered in some circumstances, but only after clarification of the diagnosis and consideration (...) of other treatment options. (shrink)

Deep Brain Stimulation (DBS) is a relatively new, experimental treatment for patients suffering from treatment-refractory Obsessive Compulsive Disorder (OCD). The effects of treatment are typically assessed with psychopathological scales that measure the amount of symptoms. However, clinical experience indicates that the effects of DBS are not limited to symptoms only: patients for instance report changes in perception, feeling stronger and more confident, and doing things unreflectively. Our aim is to get a better overview of the whole variety of changes (...) that OCD patients experience during DBS treatment. For that purpose we conducted in-depth, semi-structured interviews with 18 OCD patients. In this paper, we present the results from this qualitative study.We list the changes grouped in four domains: with regard to (a) person, (b) (social) world, (c)characteristics of person-world interactions, and (d) existential stance. We subsequently provide an interpretation of these results. In particular, we suggest that many of these changes can be seen as different expressions of the same process; namely that the experience of anxiety and tension gives way to an increased basic trust and increased reliance on one’s abilities. We then discuss the clinical implications of our findings, especially with regard to properly informing patients of what they can expect from treatment, the usefulness of including CBT in treatment, and the limitations of current measures of treatment success. We end by making several concrete suggestions for further research. (shrink)

Louis Charland has argued that the Cluster B personality disorders, including borderline personality disorder, are primarily moral rather than clinical conditions. Part of his argument stems from reflections on effective treatment of borderline personality disorder. In the argument from treatment, he claims that successful treatment of all Cluster B personality disorders requires a positive change in a patient’s moral character. Based on this claim, he concludes (1) that these disorders are, at root, deficits in moral character, and (2) (...) that effective treatment of these disorders requires a sort of moral education rather than clinical intervention. In this paper, I evaluate the argument from treatment through a critical analysis of two psychotherapeutic interventions that have shown recent effectiveness against borderline personality disorder. I suggest that both Dialectical Behaviour Therapy and Mentalization-Based Treatment indicate that borderline personality disorder is, at root, a deficit in non-moral cognitive and emotional capacities. I suggest that these non-moral deficits obscure the expression of an otherwise intact moral character. In light of this, I conclude that effective treatment of borderline personality disorder requires primarily clinical intervention rather than moral edification. (shrink)

All definitions of mental disorder are backed up by arguments that rely on general criteria (e.g., that a definition should be consistent with ordinary language). These desiderata are rarely explicitly stated, and there has been no systematic discussion of how different definitions should be assessed. To arrive at a well-founded list of desiderata, we need to know the purpose of a definition. I argue that this purpose must be practical; it should, for example, help us determine who is entitled (...) to publicly funded health care. I then propose eight conditions of adequacy that can be used to assess competing definitions (e.g., the ordinary language condition, the coherence condition, and the condition of normative adequacy). These conditions pull in different directions, however, and we must decide which are most important. I also suggest that there is no single definition that can help us deal with all the relevant practical issues. (shrink)

Attention-deficit/hyperactivity disorder (ADHD) is currently defined as a cognitive/behavioral developmental disorder where all clinical criteria are behavioral. Inattentiveness, overactivity, and impulsiveness are presently regarded as the main clinical symptoms. The dynamic developmental behavioral theory is based on the hypothesis that altered dopaminergic function plays a pivotal role by failing to modulate nondopaminergic (primarily glutamate and GABA) signal transmission appropriately. A hypofunctioning mesolimbic dopamine branch produces altered reinforcement of behavior and deficient extinction of previously reinforced behavior. This gives rise (...) to delay aversion, development of hyperactivity in novel situations, impulsiveness, deficient sustained attention, increased behavioral variability, and failure to “inhibit” responses (“disinhibition”). A hypofunctioning mesocortical dopamine branch will cause attention response deficiencies (deficient orienting responses, impaired saccadic eye movements, and poorer attention responses toward a target) and poor behavioral planning (poor executive functions). A hypofunctioning nigrostriatal dopamine branch will cause impaired modulation of motor functions and deficient nondeclarative habit learning and memory. These impairments will give rise to apparent developmental delay, clumsiness, neurological “soft signs,” and a “failure to inhibit” responses when quick reactions are required. Hypofunctioning dopamine branches represent the main individual predispositions in the present theory. The theory predicts that behavior and symptoms in ADHD result from the interplay between individual predispositions and the surroundings. The exact ADHD symptoms at a particular time in life will vary and be influenced by factors having positive or negative effects on symptom development. Altered or deficient learning and motor functions will produce special needs for optimal parenting and societal styles. Medication will to some degree normalize the underlying dopamine dysfunction and reduce the special needs of these children. The theory describes how individual predispositions interact with these conditions to produce behavioral, emotional, and cognitive effects that can turn into relatively stable behavioral patterns. Key Words: catecholamine; clumsiness; dopamine; hyperkinesis; hyperkinetic disorder; impulsivity; monoamine; neuromodulator; overactivity; pollutants; reinforcement; reward; verbally governed behavior; soft signs; variability. (shrink)

Premenstrual dysphoric disorder was recently moved to a full category in the DSM-5 . It also appears set for inclusion as a separate disorder in the ICD-11 . This paper argues that PMDD should not be listed in the DSM or the ICD at all, adding to the call to recognise PMDD as a socially constructed disorder. I first present the argument that PMDD pathologises understandable anger/distress and that to do so is potentially dangerous. I then present (...) evidence that PMDD is a culture-bound phenomenon, not a universal one. I also argue that even if medication produces a desired effect, there are biological correlates with premenstrual anger/distress, such anger/distress seems to occur monthly, and women are more likely than men to be diagnosed with affective disorders, none of these factors substantiates that premenstrual anger/distress is caused by a mental disorder. I argue that to assume they do is to ignore the now accepted role that one’s environment and psychology play in illness development, as well as arguments concerning the social construction of mental illness. In doing so, I do not claim that there are no women who experience premenstrual distress or that their distress is not a lived experience. My point is that such distress can be recognised and considered significant without being pathologised and that it is unethical to describe premenstrual anger/distress as a mental disorder. Further, if the credibility of women’s suffering is subject to doubt without a clinical diagnosis, then the way to address this problem is to change societal attitudes towards women’s suffering, not to label women as mentally ill. The paper concludes with some broader implications for women and society of the change in status of PMDD in the DSM-5 as well as a sketch of critical policy suggestions to address these implications. (shrink)

The theory of mind (ToM) deficit associated with autism has been a central topic in the debate about the modularity of the mind. Most involved in the debate about the explanation of the ToM deficit have failed to notice that autism’s status as a spectrum disorder has implications about which explanation is more plausible. In this paper, I argue that the shift from viewing autism as a unified syndrome to a spectrum disorder increases the plausibility of the explanation (...) of the ToM deficit that appeals to a domain-specific, higher-level ToM module. First, I discuss what it means to consider autism as a spectrum rather than as a unified disorder. Second, I argue for the plausibility of the modular explanation on the basis that autism is better considered as a spectrum disorder. Third, I respond to a potential challenge to my account from Philip Gerrans and Valerie Stone’s recent work (Gerrans, Biol Philos 17:305–321, 2002; Stone and Gerrans, Trends Cogn Sci 10:3–4, 2006a; Soc Neurosci 1:309–319, 2006b; Gerrans and Stone, Br J Philos Sci 59:121–141, 2008). (shrink)

Authenticity has recently emerged as an important issue in discussions of mental disorder. We show, on the basis of personal accounts and empirical studies, that many people with psychological disorders are preoccupied with questions of authenticity. Most of the data considered in this paper are from studies of people with bipolar disorder and anorexia nervosa. We distinguish the various ways in which these people view the relationship between the disorder and their sense of their authentic self. We (...) discuss the principal modern ac-counts of authenticity within the analytic philosophical tradition. We argue that accounts based on autonomous, or wholehearted, endorsement of personal characteris-tics fail to provide an adequate analysis of authenticity in the context of mental disorder. Signiﬁcant elements of true self accounts of authenticity are required. The concept of authenticity is a basic one that can be of particular value, in the context of self-development, to people with mental disorder and to others experiencing substantial inner conﬂict. (shrink)

The main thesis of this paper is that mental health practitioners can legitimately infer that a patient's given condition is a case of mental disorder without having diagnosed any specific mental disorder. The article shows how this is justifiable by relying either on psychopathological reasoning, on 'intentional' analysis or possibly on other modes of reasoning. In the end, it highlights the clinical and philosophical consequences of the plurality of modes of 'inferences to mental disorder'.

In this article, I argue that persons suffering from Body Integrity Identity Disorder (BIID) can give informed consent to surgical measures designed to treat this disorder. This is true even if the surgery seems radical or irrational to most people. The decision to have surgery made by a BIID patient is not necessarily coerced, incompetent or uninformed. If surgery for BIID is offered, there should certainly be a screening process in place to insure informed consent. It is beyond (...) the scope of this work, however, to define all the conditions that should be placed on the availability of surgery. However, I argue, given the similarities between BIID and gender dysphoria and the success of such gatekeeping measures for the surgical treatment of gender dysphoria, it is reasonable that similar conditions be in place for BIID. Once other treatment options are tried and gatekeeping measures satisfied, A BIID patient can give informed consent to radical surgery. (shrink)

Many contemporary bioethicists claim that the possession of certain psychological properties is sufficient for having full moral status. I will call this thepsychological approach to full moral status. In this paper, I argue that there is a significant tension between the psychological approach and a widely held model of Dissociative Identity Disorder (DID, formerly Multiple Personality Disorder). According to this model, the individual personalities or alters that belong to someone with DID possess those properties that proponents of the (...) psychological approach claim suffice for full moral status. If this account of DID is true, then the psychological approach to full moral status seems to entail that the two standard therapies for treating DID might, on occasion, be seriously immoral, for they may well involve the (involuntary) elimination of an entity with full moral status. This result should give proponents of the psychological approach pause, for most people find the claim that current treatments of DID are ethically suspect highly counter-intuitive. (shrink)

Autonomy is a fundamental though contested concept both in philosophy and the broader intellectual culture of today’s liberal societies. For instance, most of us place great value on the opportunity to make our own decisions and to lead a life of our own choosing. Yet, there is stark disagreement on what is involved in being able to decide autonomously, as well as how important this is compared to other commitments. For example, the success of every group project requires that group (...) members make decisions about the project collectively rather than each on their own. This disagreement notwithstanding, mental disorder is routinely assumed to put a strain on autonomy; however, it is unclear whether this is effectively the case and, if so, whether this is due to the nature of mental disorder or the social stigma that often attaches to it. This book is the first exploration of the nature and value of autonomy with reference to mental disorder. By reflecting on instances of mental disorder where autonomy is apparently compromised, it offers a systematic discussion of the underlying presuppositions of the present autonomy debates in philosophy and psychiatry. In so doing, it helps address different kinds of emerging scepticism questioning either the appeal of autonomy as a concept or its relevance to specific areas of normative ethics, including psychiatric ethics. (shrink)

This paper will examine the way in which premenstrual symptomatology has been represented and regulated by psychology and psychiatry. It questions the “truths” about women's premenstrual experiences that circulate in scientific discourse, namely the fictions framed as facts that serve to regulate femininity, reproduction, and what it is to be “woman.” Hegemonic truths that define Premenstrual Dysphoric Disorder (PMDD) and its nosological predecessor Premenstrual Syndrome (PMS) are examined to illustrate how regimes of objectified knowledge and practices of “assemblage” come (...) to regulate individual women through a process of subjectification. Five interconnected “truths” are presented as objects of scrutiny: PMDD is a thing that can be objectively defined and measured; PMDD is a pathology to be eradicated; PMDD is caused and can be treated by one factor; PMDD is a bodily phenomenon; PMDD causes women's problems or symptoms. I examine the way in which these hegemonic truths function in framing the reproductive body as a cause of disorder or distress that leads women to interpret premenstrual experiences within a pathological framework deserving medical or psychological treatment. Finally, I offer an alternative framework drawing on Eastern models of selfhood that provides a more empowering model of women's premenstrual experiences. (shrink)

. Current debates concerning the concept of mental disorder involve many different philosophical issues. However, it is not always clear from these discussions how, or whether, these issues relate to one another, or in exactly what way they are important for the definition of disorder. This article aims to sort through some of the philosophical issues that arise in the current literature and provide a clarification of how these issues are related to one another and whether they are (...) necessary for defining disorder. I argue that the main concern in defining disorder, namely demarcation, is obscured by a number of these other philosophical issues and that a focus on demarcation gives us a means of placing these other issues in a clarifying context. (shrink)

This paper outlines a multidimensional conception of Multiple Personality Disorder (MPD) that differs from the 'orthodox' conception in terms of the content of its commitment to the reality of the self. Unlike the orthodox conception it recognizes that selves are fuzzy entities. By appreciating the possibility that selves are fuzzy entities, it is possible to rebut a form of fictionalism about the self which appeals to clinical data from MPD. Realism about self can be preserved in the face of (...) multiple personalities. (shrink)

I shall begin with the "anti-psychiatry" view that the lack of a physical basis excludes many familiar mental disorders from the category of "illness". My response to this argument will be that anti-psychiatrists are probably right to hold that most mental disorders do not involve any physical disorder, but that they are wrong to conclude from this that these mental disorders are not illnesses.

This is a response to an article published inSociety & Animals in 2008 that argued for the existence of a “species identity disorder” in some furries. Species identity disorder is modeled on gender identity disorder, itself a highly controversial diagnosis that has been criticized for pathologizing homosexuality and transgendered people. This response examines the claims of the article and suggests that the typology it constructs is based on unexamined assumptions about what constitutes “human” identity and regulatory fictions (...) of gender identity. (shrink)

Content analysis of three chapters of Jamison’s memoir, An Unquiet Mind, shows that depression, mania, and Bipolar Disorder have a common metaphoric core as a sequential process of suffering and adversity that is a form of malevolence and destruction. Depression was down and in, while mania was up, in and distant, circular and zigzag, a powerful force of quickness and motion, fieriness, strangeness, seduction, expansive extravagance, and acuity. Bipolar Disorder is down and away and a sequential and cyclical (...) process that partakes of the metaphors of its component moods. We conclude that metaphors of mood disorders share a number of structural features and are consistent across different authors. (shrink)

A link between mental disorder and freedom is clearly present in the introduction of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It mentions “an important loss of freedom” as one of the possible defining features of mental disorder. Meanwhile, it remains unclear how “an important loss of freedom” should be understood. In order to get a clearer view on the relationship between mental disorder and (a loss of) freedom, in this article, (...) I will explore the link between mental disorder and free will. I examine two domains in which a connection between mental disorder and free will is present: the philosophy of free will and forensic psychiatry. As it turns out, philosophers of free will frequently refer to mental disorders as conditions that compromise free will and reduce moral responsibility. In addition, in forensic psychiatry, the rationale for the assessment of criminal responsibility is often explained by referring to the fact that mental disorders can compromise free will. Yet, in both domains, it remains unclear in what way free will is compromised by mental disorders. Based on the philosophical debate, I discuss three senses of free will and explore their relevance to mental disorders. I conclude that in order to further clarify the relationship between free will and mental disorder, the accounts of people who have actually experienced the impact of a mental disorder should be included in future research. (shrink)

Marya Schechtman argues that psychological continuity accounts of personal identity, as represented by Derek Parfit's account, fail to escape the circularity objection. She claims that Parfit's deployment of quasi-memory (and other quasi-psychological) states to escape circularity implicitly commit us to an implausible view of human psychology. Schechtman suggests that what is lacking here is a coherence condition, and that this is something essential in any account of personal identity. In response to this I argue first that circularity may be escaped (...) using quasi-psychological states even with the addition of the coherence condition. Second, I argue that there is something right about the coherence condition, and a major task of this paper is to identify its proper theoretical role. I do so by reflection on integration therapies for people with multiple personality disorder (MPD). The familiar distinction between the moral and the metaphysical concept of the person is developed alongside such reflection. Connecting these two issues I argue that coherence acts as a normative constraint on accounts of personal identity, but that the normative dimension of personhood is not essential to our notion of a person tout court. (shrink)

Some would say that philosophy can contribute more to the occurrence of mental disorder than to the study of it. Thinking too much does have its risks, but so do willful ignorance and selective inattention. Well, what can philosophy contribute? It is not equipped to enumerate the symptoms and varieties of disorder or to identify their diverse causes, much less offer cures (maybe it can do that-personal philosophical therapy is now available in the Netherlands). On the other hand, (...) the scientific study of mental disorder has a long way to go. There is much disagreement and uncertainty about the nature, causes, and treatment of many specific disorders, as is evident from DSM's classification of them in predominantly symptomatic terms. And even if what is reflected in DSM were a consensus rather than a compromise, still this shifts periodically with each new edition. Moreover, it is a notorious fact that many patients who clearly have psychiatric abnormalities do not fit any of the recognized diagnostic categories.1. (shrink)

The purpose of this inquiry is to explore the experience of Borderline Personality Disorder with the aim of developing a more liberating approach to its diagnosis and treatment. Eight participants diagnosed with Borderline Personality Disorder were recruited from a psychiatric hospital operated by the Surrey and Borders NHS Trust and an outpatient daycentre based in London, United Kingdom. A narrative approach to methodology was employed to collect and analyse the participants’ life-stories. Themes to emerge from the participant’s narratives (...) were found to coincide with R.D. Laing’s concept of ontological insecurity. Ontological insecurity describes a number of aspects of the participant’s distress. To conclude, some general implications of this research for psychotherapy are briefly explored. (shrink)

In this paper we argue that dissociative identity disorder (DID) is best interpreted as a causal model of a (possible) post-traumatic psychological process, as a mechanical model of an abnormal psychological condition. From this perspective we examine and criticize the evidential status of DID, and we demonstrate that there is really no good reason to believe that anyone has ever suffered from DID so understood. This is so because the proponents of DID violate basic methodological principles of good causal (...) modeling. When every ounce of your concentration is fixed upon blasting a winged pig out of the sky, you do not question its species' ontological status. James Morrow, City of Truth (1990). (shrink)

During the last years, there has been an important discussion on the concept of mental disorder. Several accounts of such a concept have been offered by theorists, although neither of these accounts seems to have successfully answered both the question of what it means for a certain mental condition to be a disorder and the question of what it means for a certain disorder to be mental. In this paper, I propose an account of the concept of (...) mental disorder that, if I am right, provides satisfactory answers to both of these questions. Furthermore, this account (unlike other accounts presented in the literature on the subject) meets the requirements for achieving a crucial goal underlying the project of sorting out the concept of mental disorder, namely the goal of allowing the existence of a dialogue between mental health professionals of different theoretical orientations. To achieve this goal, the account herein proposed is not based in any particular theoretical framework, but in both ordinary and technical theory-neutral concepts. In the last part of the paper, I argue that it follows from most accounts of the concept of mental disorder that the disciplines concerned with explaining some mental disorders are not branches of medicine, and that the treatment of some mental disorders is not a matter of medical intervention. (shrink)

Weakness of will has perplexed philosophers since Plato's time. This chapter places some of the literature on volitional disorders and addictions in a philosophical context dating back to Plato and Aristotle in an attempt to shed light on issues that a theorist who wishes to analyze the idea of a volitional disorder will face. Key here is the notion of the irresistability and resistability of pertinent desires, which is explored in relation to George Ainslie's work on the ability to (...) make and adhere to personal rules. (shrink)

The concept of mental disorder is often defined by reference to the notion of mental dysfunction, which is in line with how the concept of disease in somatic medicine is often defined. However, the notions of mental function and dysfunction seem to suffer from some problems that do not affect models of physiological function. Functions in general have a teleological structure; they are effects of traits that are supposed to have a particular purpose, such that, for example, the heart (...) serves the goal of pumping blood. But can we single out mental functions in the same way? Can we identify mental functions scientifically, for instance, by applying evolutionary theory? Or are models of mental functions necessarily value-laden? I want to identify several philosophical problems regarding the notion of mental function and dysfunction and point out some possible solutions. As long as these questions remain unanswered, definitions of mental disorder that rest upon the concept of mental dysfunction will lack a secure foundation. (shrink)

According to the predominant view within contemporary philosophy of psychiatry, mental disorders involve essentially personal and societal values, and thus, the concept of mental disorder cannot, even in principle, be elucidated in a thoroughly objective manner. Several arguments have been adduced in support of this impossibility thesis. My critical examination of two master arguments advanced to this effect by Derek Bolton and Jerome Wakefield, respectively, raises serious doubts about their soundness. Furthermore, I articulate an alternative, thoroughly objective, though in (...) part normative, framework for the elucidation of the concept of mental disorder. The concepts of mental dysfunction and impairment of basic psychological capacities to satisfy one’s basic needs are the building blocks of this framework. I provide an argument for the objective harmfulness of genuine mental disorders as patterns of mental dysfunctions with objectively negative biotic values, as well as a formally correct definition of the concept of mental disorder. Contrary to the received view, this objective framework allows for the possibility of genuine mental disorders due to adverse social conditions, as well as for quasi-universal mental disorders. I conclude that overall, the project of providing an objective account of the concept of mental disorder is far from impossible, and moreover, that it is, at least in principle, feasible. (shrink)

Upon first consideration, the desire of an individual to amputate a seemingly healthy limb is a foreign, perhaps unsettling, concept. It is, however, a reality faced by those who suffer from body integrity identity disorder (BIID). In seeking treatment, these individuals request surgery that challenges both the statutory provisions that sanction surgical operations and the limits of consent as a defence in New Zealand. In doing so, questions as to the influence of public policy and the extent of personal (...) autonomy become important. Beyond legal issues, BIID confronts dominant conceptions of bodily integrity, medical treatment, and ethical obligations. This paper seeks to identify the relevant public policy concerns raised by BIID in New Zealand and the limits of autonomy, before moving on to consider how BIID sufferers may legally seek the treatment they require and how a doctor might be protected from criminal proceedings for assault for performing this treatment. It will be argued that it is possible to legally consent to the amputation of a healthy limb as medical treatment and that public perception should not be allowed to take precedence over this right. (shrink)

In the Timaeus, Plato makes a distinction between reason and necessity. This distinction is often accounted for as a distinction between two types of causation: purpose oriented causation and mechanistic causation. While reason is associated with the soul and taken to bring about its effects with the good and the beautiful as the end, necessity is understood in terms of a set of natural laws pertaining to material things. In this paper I shall suggest that there are reasons to reconsider (...) the latter part of this account and argue for a non-mechanistic understanding of necessity. I will first outline how the notion of necessity is introduced in the dialogue. I will then show how a mechanistic account of necessity fails to capture Plato’s purpose of treating it as a causal factor; and, finally, argue that this purpose is better understood as an attempt, on Plato’s part, to account for the causal origin of disorder and irrationality, an origin articulated in terms of a pre-cosmic situation and the notoriously difficult notion of the third kind. (shrink)

The "conservative" holds that mental disorder exculpates only if it is evidence of a standard excuse or justification, i.e., one that a mentally "normal" person could have. The Liberal holds that mental disorder sometimes exculpates in itself. I argue that moral culpability in the case of mental disorder is often moot, and that the real issue is what a court should be allowed to do with such individuals. This undermines the idea that culpability is a necessary condition (...) for sentencing, but we already have that in cases of strict liability, and there seems to be no viable alternative in any case. (shrink)

What mental disorder means is controversial. I attempt to solve that controversy by applying the method of defining a phenomenon in terms of the goals we have for demarcating that phenomenon from other phenomena to the case of mental disorder. I thus address the question about the nature of mental disorder by paying attention to the goals we have for demarcating mental disorder. I maintain that these goals, which embody the reasons why we consider mental (...) class='Hi'>disorder a significant phenomenon for us, have a common denominator: they refer to psychological capacity for autonomy. I present a conceptual foundation for defining mental disorder on the basis of that psychological capacity and argue that this way of understanding the nature of mental disorder avoids the main problems of the central contemporary theories of mental disorder. Then I explain why this conception of the nature of mental disorder is not undermined by anti-psychiatric criticisms to the effect that mental illness does not exist, that the mentally ill should not be treated differently from others, and that seeing problems of the mentally disordered as psychiatric problems is unjustified medicalization. I conclude by suggesting that the presented conceptual foundation for defining mental disorder would benefit from being complemented by results of empirical psychology. (shrink)

It is commonly thought that mental disorder is a valid concept only in so far as it is an extension of or continuous with the concept of physical disorder. A valid extension has to meet two criteria: determination and coherence. Essentialists meet these criteria through necessary and sufficient conditions for being a disorder. Two Wittgensteinian alternatives to essentialism are considered and assessed against the two criteria. These are the family resemblance approach and the secondary sense approach. Where (...) the focus is solely on the characteristics or attributes of things, both these approaches seem to fail to meet the criteria for valid extension. However, this focus on attributes is mistaken. The criteria for valid extension are met in the case of family resemblance by the pattern of characteristics associated with a concept, and by the limits of intelligibility of applying a concept. Secondary sense, though it may have some claims to be a good account of the relation between physical and mental disorder, cannot claim to meet the two criteria of valid extension. (shrink)

Theoretical models for physician-patient communication in clinical practice are described in literature, but none of them seems adequate for solving the communication problem in clinical practice that emerges in case of factitious disorder. Theoretical models generally imply open communication and respect for the autonomy of the patient. In factitious disorder, the physician is confronted by lies and (self)destructive behaviour of the patient, who in one way or another tries to involve the physician in this behaviour. It is no (...) longer controversial that the physician should communicate his consideration of a factitious disorder without insistence that the patient accepts this diagnosis. However, the balance between patient autonomy and open communication on the one hand, and the preservation of the patient's health, physician integrity and of a constructive physician-patient relationship on the other is easily disrupted. In this article, an epistemological model is described to facilitate a positive outcome of confrontation in treatment of factitious disorder. Analysing the problem in terms of systems theory will help the physician to assess what information is appropriate to use in which phase of the patient's treatment, while preserving the physician-patient relationship. (shrink)

Psychologists and cultural historians typically have argued that early modern theologians such as Martin Luther, John Bunyan, and Ignatius Loyola exhibited behavior that the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) classifies as a subtype of obsessive-compulsive disorder termed “religious scrupulosity.” This essay argues that, although early modern theologians do manifest scrupulosity, such religiosity was a culturally acceptable, even recommended component of spiritual progress, a necessary means of receiving an unmerited bestowal of God’s grace. The larger aim (...) of the essay is to point out some of the limitations of current DSM criteria when attempting retrospectively to diagnose historical figures with mental pathology. (shrink)

Gender Identity Disorder (GID) is regarded as a mental illness and included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It will also appear in the DSM-V, due to be published in 2013. The classification of GID as a mental illness is contentious. But what would happen to sufferers if it were removed from the diagnostic manuals? Would people lose their entitlement to funded medical care, or to reimbursement under insurance schemes? On what basis should medical treatment (...) for GID be provided? What are the moral arguments for and against funded or reimbursed medical care for GID? This paper starts out with a fiction: GID is removed from the diagnostic manuals. Then the paper splits in two, as in happened in the Howitt’s 1998 film Sliding Doors . The two scenarios run parallel. In one, it is argued that GID is on a par with other body modifications, such as cosmetic and racial surgery, and that, for ethical reasons, treatment for GID should be privately negotiated by applicants and professionals and privately paid for. In the other scenario, it is argued that the comparison between GID and other body modifications is misleading. Whether or not medical treatment should be funded or reimbursed is independent of whether GID is on a par with other forms of body dissatisfaction. (shrink)

Attention deficit hyperactivity disorder is a developmental disorder with an age onset prior to 7 years. Children with ADHD have significantly lower ability to focus and sustain attention and also score higher on impulsivity and hyperactivity. Stimulants, such as methylphenidate, have remained the mainstay of ADHD treatment for decades with evidence supporting their use. However, recent years have seen emergence of newer drugs and drug delivery systems, like osmotic release oral systems and transdermal patches, to mention a few. (...) The use of nonstimulant drugs like atomoxetine and various other drugs, such as a-agonists, and a few antidepressants, being used in an off-label manner, have added to the pharmacotherapy of ADHD. This review discusses current trends in drug therapy of ADHD and highlights the promise pharmacogenomics may hold in the future. (shrink)

This is a response to Professor Fennell's paper on the recent influence and impact of the best interests test on the treatment of patients detained under the Mental Health Act 1983 (MHA) for mental disorder. I discuss two points of general ethical significance raised by Professor Fennell. Firstly, I consider his argument on the breadth of the best interests test, incorporating as it does factors considerably wider than those of medical justifications and the risk of harm. Secondly, I discuss (...) his contention that the apparent permeability of the line between the interests of the patient and the interests of society is something to be concerned about in itself. Since the overarching theme of the paper is the proper place of social and cultural values, my reponse considers the implications of Fennell's arguments in the light of Charlotte Brontë's novel ‘Jane Eyre’, which, through the character of Bertha Mason (the infamous ‘mad woman in the attic’) provides a provocative study of the relationship between mental disorder and society. (shrink)

Periodic attacks of uncertain origin, where the clinical presentationresembles epilepsy but there is no evidence of a somatic disease, arecalled Pseudo-Epilepsy or Pseudo-Epileptic Attack Disorder (PEAD). PEADmay be called a `non-disease', i.e. a disorder on the fringes ofestablished disease patterns, because it lacks a rationalpathophysiological explanation. The first aim of this article is tocriticize the idea, common in medical science, that diseases are realentities which exist separately from the patient, waiting to bediscovered by the doctor. We argue that (...) doctor and patient construct adisease, and that the construction of the disease PEAD includes manynormative evaluations. The second aim is to provide insight into thesuffering of patients with PEAD. We focus on three aspects of thepatient, identity, autonomy and responsibility. We present somecharacteristic descriptions of (pseudo-)epileptic attacks by FjodorDostoevsky, Gustave Flaubert and Thomas Mann. We argue that diagnosingPEAD reduces a meaningful life event into an insignificant, thoughintriguing, medical phenomenon, and that the patient will not benefitfrom being diagnosed as having PEAD. (shrink)

This paper aims to contribute to the exploration of the shift from a problematisation of ‘unwed motherhood’ to ‘teenage motherhood’ in late twentieth century Britain. It does so by exploring the dominant social scientific understanding of ‘unwed mothers’ during the 1950s and 1960s which suggested that these women suffered from a psychological disorder. I then analyse the conceptualisation of ‘adolescent unwed mothers’ exploring why professionals deemed them to be less disturbed than older women in their predicament. This finding is (...) discussed in light of contemporary social scientific concern with adolescent motherhood. (shrink)

In Kise and Ngyuen’s “Adult Baby Syndrome and Gender Identity Disorder” (2011), the authors refer to their male subject as “Ms B” because he prefers to identify with being a female. But they do not refer to her as being a baby, even though the subject also prefers to identify with being a baby. This shows that although they respect the subject’s gender identity preferences, they do not respect the subject’s age identity preferences. One reason for this might be (...) that some people feel the term “adult baby syndrome” sounds a bit silly and therefore that the wishes of someone having this syndrome are not worthy of being taken seriously, not as seriously, at least, as someone who shows the more scientifically respectable gender identity disorder. A solution here might be to replace the term “adult baby syndrome” with the term “age identity disorder”, perhaps involving “age dysphoria”. This would also be more accurate because not all of those who are discussed under the heading of “adult baby syndrome” wish to be identified as babies, but rather as toddlers or older children. The problem then is that numerous people prefer to identify with being a different age. Such people do not believe they are older or younger than they really are, but neither do those with adult baby syndrome. (shrink)

Is Female Genital Cosmetic Surgery for an adolescent with Body Dysmorphic Disorder ever ethically justified? Cosmetic genital surgery for adolescent girls is one of the most ethically controversial forms of cosmetic surgery and Body Dysmorphic Disorder is typically seen as a contraindication for cosmetic surgery. Two key ethical concerns are that Body Dysmorphic Disorder undermines whatever capacity for autonomy the adolescent has; and even if there is valid parental consent, the presence of Body Dysmorphic Disorder means (...) that cosmetic surgery will fail in its aims. In this article, we challenge, in an evidence-based way, the standard view that Body Dysmorphic Disorder is a contraindication for genital cosmetic surgery in adolescents. Our argument gathers together and unifies a substantial amount of disparate research in the context of an ethical argument. We focus on empirical questions about benefit and harm, because these are ethically significant. Answers to these questions affect the answer to the ethical question. We question the claim that there would be no benefit from surgery in this situation, and we consider possible harms that might be done if treatment is refused. For an adolescent with Body Dysmorphic Disorder, the most important thing may be to avoid harm. We find ourselves arguing for the ethical justifiability of cosmetic labioplasty for an adolescent with Body Dysmorphic Disorder, even though we recognize that it is a counter intuitive position. We explain how we reached our conclusion. (shrink)